Influence of teach-back strategy on hemodialysis related knowledge level, self-efficacy and self-management in patients receiving maintenance hemodialysis

To investigate the effect of teach-back strategy on hemodialysis related knowledge level, self-efficacy and self-management among hemodialysis patients. The research is a quasi-randomized control trial. A total of 92 patients receiving maintenance hemodialysis were randomly divided into observation group (n = 46) and control group (n = 46) by random number table method. The control group received conventional health education, and the observation group received teach-back. The intervention lasted six months. The hemodialysis related knowledge level, self-efficacy and self-management of the two groups were evaluated before and after the intervention. There were no significant difference on hemodialysis related knowledge level, self-efficacy and self-management scores between the two groups before intervention (P > 0.05). After intervention, the scores of hemodialysis knowledge in the observation group was higher than that in the control group and before intervention. The total scores of self-efficacy and items “3,4,5” were higher than those of the control group. The total scores of self-efficacy and item “1~6” in the observation group were higher than before intervention. The total scores of self-management and the three subscales of “problem solving”, “partnership” and “emotional processing” were higher than those of the control group and before intervention. All of the above differences were statistically significant (P < 0.05). Teach-back is helpful to improve the hemodialysis related knowledge level, self-efficacy and self-management level of patients receiving maintenance hemodialysis, and it is worth to be popularized clinically.


Setting
Control group: Conventional health education.Researchers used WeChat official account and Tencent QQ platform to conduct individualized health education for participants.The contents include the basic knowledge of hemodialysis, drug guidance, fluid intake, diet guidance of low phosphorus and low potassium, the significance of regular dialysis and regular examination, vascular access nursing, etc.The form of health education is mainly taught by researchers.Patients were asked questions every two weeks for 1 to 1.5 h 12 times over a period of 6 months.The question-and-answer session was conducted during hemodialysis treatment.
Observation group: Teach-back.The research team consists of 1 doctor, 1 head nurse, 2 national nurses specializing in blood purification and 2 graduate students.The research team members uniformly received the training of teach-back related theories and implementation skills, and were assessed after the training.Doing so would ensure homogeneity in the implementation of the intervention.An accessible education manual suitable for patients receiving MHD was developed and revised after repeated discussion by our research team.The researchers divided 46 participants into four groups of 10 to 12 people each.The intervention was administered every two weeks for 1 to 1.5 h and 12 times over 6 months.The intervention site was in the hemodialysis reception room.

Intervention procedure
Teach-back consists of the following five steps: (1) Convey information.Researchers should be careful to use nonmedical terms, speak at a moderate pace, and step by step when explaining or demonstrating hemodialysis related knowledge to patients in accordance with the content of the health education program.Illustrations, multimedia and other auxiliary tools can be used to explain.The researchers selected two to three topics of 20-25 min each and informed the patients about the significance of the topics.(2) Repeat information.After the researchers' health education, patients were asked to repeat the information in their own words.In the field demonstration part, researchers should pay attention to create a relaxed atmosphere and ask questions in a moderate tone.The time is 15 to 20 min each time.(3) Effect evaluation.After the patients repeated or demonstrated the information, the researchers evaluated the effect of the repeated information to understand the patients' understanding and mastery of the information knowledge.The time is 5-10 min each time.(4) Clarification.Patients did not understand or understood the content of ambiguity, the researchers used different words or tools to explain and clarify again.If the patient could not understand correctly after 2 or 3 times of clarification by the researcher, the patient should change other health education methods to explain until the patient could understand correctly.The time is 15-20 min each time.(5) Open-ended questions.
Patients were asked open-ended questions at the end of the session, such as "Is there anything you don't understand?".If the patient can correctly and comprehensively understand the content of health education, then the health education is finished, otherwise, repeat steps 1 to 5 until the patient has fully grasped.The time is 5 to 10 min each time.www.nature.com/scientificreports/

Measures
Hemodialysis related knowledge scale, self-efficacy for managing chronic disease 6-item scale and self-management scale for hemodialysis patients were used to evaluate the hemodialysis related knowledge level, selfefficacy and self-management of patients receiving MHD before and after intervention (Baseline, after 6 months of intervention).Hemodialysis related knowledge scale 12 .The scale is used to evaluate the knowledge level of hemodialysis in patients receiving MHD.A two-point Likert scale (0 = "wrong answer or don't know" to 1 = "correct answer") is used and the total score of 25 items varies from 0 to 25, with higher scores suggesting a higher level of knowledge.The instrument has been proven to be valid and reliable, and has been used among Chinese hemodialysis patients 13 .In this study, the Cronbach's alpha coefficient was 0.701.
Self-efficacy for managing chronic disease 6-item scale 14 .The scale includes 2 subscales: symptom management (fatigue, shortness of breath, pain, role function, depression, and health distress) and common disease management (take medicine as prescribed and adopt health care behaviors).A visual analogue scale (VAS) (1 = "have no confidence" to 10 = "have every confidence") is used and the total score of 6 items varies from 6 to 60, with higher scores suggesting a higher level of self-efficacy.In this study, the Cronbach's alpha coefficient was 0.910.
Self-management scale for hemodialysis patients.The scale includes 4 subscales: problem solving, perform self-care activities, partnership and emotional processing.A four-point Likert scale (1 = "never" to 4 = "always") is used and the total score of 20 items varies from 20 to 80, with higher scores suggesting a higher level of selfmanagement.The instrument was developed by Chinese scholars and has proved to be valid and reliable 15 .In this study, the Cronbach's alpha coefficient was 0.811, and the Cronbach's alpha of 4 subscales ranged from 0.736 to 0.829.

Comparison of self-efficacy scores between the two groups before and after intervention
After 6 months of intervention, the total score of self-efficacy and the scores of item "3,4,5" in the observation group were higher than those in the control group.The total score of self-efficacy and the scores of items "1-6" in the observation group were higher than those before the intervention.These differences were statistically significant (P < 0.05).Table 3 compares the self-efficacy scores between the two groups before and after intervention.

Comparison of self-management scores between the two groups before and after intervention
After 6 months of intervention, the total score of self-management and three subscales (problem solving, partnership and emotional processing) in the observation group were higher than those in the control group and before intervention.These differences were statistically significant (P < 0.05).Table 4 compares the self-management scores between the two groups before and after intervention.

Discussion
Teach-back strategy is in line with the concept of the "learning pyramid" 16 .In the process of health education, researchers mobilize the enthusiasm of patients to learn by drawing, video, group discussion, retelling and practical exercise, so that patients can master relevant knowledge through active participation.The results of this study show that teach-back has obvious advantages over conventional health education in improving the hemodialysis related knowledge level of patients receiving MHD.The reasons are as follows: First, it has been reported that 40% ~ 80% of the medical information delivered to patients by conventional health education will be forgotten by them, and 50% of the information saved in patients' memory is wrong 17 .Teach-back overcomes the disadvantages of simple form and one-way transmission, and pays more attention to two-way communication with patients 18 .Second, after receiving the knowledge, patients gave feedback, which improved their initiative to participate.Third, the researchers evaluated the patients after their feedback, and the knowledge that the patients did not master was taught again until they fully grasped it.Four, the intervention strategy of centralized learning makes patients discuss with each other, which enhances the efficiency of health education.It suggests that medical staff should translate the professional knowledge of hemodialysis into plain language when conducting health education for patients, so as to stimulate the initiative and interest of patients receiving MHD in learning.
The self-efficacy and self-management level of patients receiving MHD before intervention in this study were similar to the previous study result 19 , which suggests that there is still much room for improvement in self-efficacy and self-management level.After six months of teach-back intervention, the self-efficacy and self-management level of patients receiving MHD were significantly improved.It has been reported that the hemodialysis related knowledge level of patients receiving MHD was positively correlated with self-efficacy and self-management [20][21][22] .With the improvement of patients' knowledge level, their confidence and ability to manage their own symptoms are enhanced, so as to improve their self-efficacy and self-management level.The results of this study showed that after 6 months of intervention, the scores of items "1,2,6" in the self-efficacy scale in the observation group were not statistically significant compared with those in the control group.This may be related to the long disease cycle and many dialysis complications in patients receiving MHD, which are difficult to improve in the short term, such as fatigue, physical discomfort, and the impact on daily life.The results of this study showed that after 6 months of intervention, the score of "perform self-care activities" in the self-management scale in the observation group were not statistically significant compared with those in the control group.This may be related to the fact that the study intervention was limited to the education of knowledge and paid less attention to perform self-care activities.It suggests that medical staff should not only give theoretical knowledge education, but also strengthen the mastery of patients' self-care skills when carrying out health education for patients.At the same time, healthcare providers should guide patients on regular dialysis, proper exercise and nutrition to reduce their complications, and give appropriate psychological counseling to improve their confidence and ability, so as to further improve their self-efficacy and self-management level.
This study has several limitations.First, the data were collected from single center, which might not be representative of all patients receiving MHD.Second, the intervention time was short, and there was no long-term health education.Third, this study only conducted random grouping, not random sampling.In the future, it will be interesting to further explore the applicability and intervention effect of teach-back in health education for patients receiving MHD by increasing study samples, extending the intervention time, and improving the study design.
In conclusion, this study applied the teach-back strategy to the health education of patients receiving MHD, which is scientific, effective, low-cost, and could strongly improve their self-efficacy and self-management level.The improvement of self-efficacy and self-management level will help to improve the prognosis and quality of life of patients receiving MHD, and prolong the duration of dialysis.

Table 2 .
Comparison of hemodialysis related knowledge scores between the two groups before and after intervention.

Table 3 .
Comparison of self-efficacy scores between the two groups before and after intervention.

Table 4 .
Comparison of self-management scores between the two groups before and after intervention.
*Represents comparison with self before intervention, P < 0.05.